Question

Scenario J.G., a 69-year-old man, was seen in the emergency department (ED) 2 days ago, diagnosed (Dx) with alcohol intoxication, and released after 8 hours to his brother’s care. He was brought back to the ED 12 hours ago with an active gastrointestinal (GI) bleed and is being admitted to ICU; his diagnosis is upper GI bleed and alcohol intoxication. You are assigned to admit and care for J.G. for the remainder of your shift. According to the ED notes, his admission vital signs (VS) were 84/56, 110, 26, and he was vomiting bright red blood. His labs were remarkable for Hct 23%, alanine transaminase (ALT) 69 IU/ml, aspartate transaminase (AST) 111 IU/ml, and serum alcohol (ETOH) 271 mg/dl. He was given IV ?uids and transfused 6 units of packed RBCs (PRBCs) in the ED. On initial assessment, you note that J.G.’s VS are blood pressure (BP) 154/90 mm Hg, pulse 98 beats/min; he has a slight tremor in his hands, and he appears anxious. He complains of a headache and appears ?ushed. You note that he has not had any emesis and has not had any frank red blood in his stool or “black tarry stools” over the past 5 hours. In response to your questions, J.G. denies that he has an alcohol problem but later admits to drinking approximately a ?fth of vodka daily for the past 2 months. He reports having been drinking just before his admission to the ED. He admits to having had seizures while withdrawing from alcohol in the past. 1. Which data from your assessment of J.G. are of concern to you? 2. What is the 2 most likely causes of J.G.’s symptoms? 3. What is the most likely time frame for someone to have withdrawal symptoms after abrupt cessation of alcohol? 4. What are the characteristics of alcohol withdrawal syndrome (delirium tremens)? CASE STUDY PROGRESS You note that J.G.’s physician has not diagnosed J.G. as having alcohol dependence, and his orders do not include treatment for alcohol withdrawal. 5. What action is necessary before you continue to care for J.G.? 6. What is the difference between alcohol dependence and alcohol abuse? 7. What would be helpful for J.G.’s physician to know regarding J.G.’s substance abuse history? 8. What are the 3 main objectives of treatment of chronic alcoholism? 9. Which clinical assessment tool is commonly used to monitor withdrawal symptoms? Explain how it is used. 10. What class medications are commonly prescribed for patients withdrawing from alcohol? List 2 examples of each class. 11. What chronic health problems are associated with alcoholism? Give 2 examples of each. 12. What other medical problems will you need to be aware of as he provides J.G.’s treatment for alcohol withdrawal? How could you help assess for these problems? List 5 assessment questions. 13. What lab tests might be ordered to assess for nutritional de?ciencies or other medical problems J.G. is experiencing? 14. What types of education and referral should be done before J.G.’s discharge from the hospital? List 4 15. What medications (List 3) might be prescribed to J.G. to assist him with sobriety? What is the usual treatment regimen, and what side effects and precautions should you educate the patient about concerning each?

Answer 1

ANSWER 1) On assessment in the initial phase, when Mr.J.G is brought to ED with bright red vomiting, the alarming signs that need immediate attention is low blood pressure of 84/56 mmHg, hematocrit of 23% which is low (normal is 40%-54%), and blood alcohol level of 271 mg/dl which is characteristic of alcohol intoxication.

After the bleeding subside, the other assessment that is of concern is high blood pressure of 154/90mmHg, tremors and headache along with the history of alcohol intake. These are the symptoms for alcohol withdrawal syndrome.

ANSWER 2) Main cause of symptoms are:

• The fall of blood pressure and hematocrit level is due to decreased blood volume caused by gastrointestinal bleeding..
• The other symptoms are due to abrupt withdrawal of alcohol called delirium tremens which precipitate symptoms.

ANSWER 3) A person develops withdrawal symptoms after six hours of abrupt cessation of alcohol intake. These symptoms develops 2-3 days after stopping heavy drinking and by 4-6 days develops severe manifestations

ANSWER 4) The alcohol withdrawal syndrome is characterized by anxiety, shakiness, sweating, vomiting,mild fever. The severe symtoms include seizures, seeing or hearing things that others do not,delirium tremens. When person develops delirium tremens, he appears confused, tremors occur in extremities

Alcohol positive allosterically modulate the binding of GABA which combined with desensitization of Alpha 2 adrenergic receptors results in hemostatic upregulation of these systems in chronic alcohol use. When we sto alcohol intake abruptly, the unregulated mechanism result in hyperexcitability of neurons of as natural GABA . This combined with increased nonadrenergic activity develops the symptoms of delirium tremens.